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ASN Wikibase Occurrence # 65505
Last updated: 5 July 2019
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Date:09-JUN-2009
Time:21:35
Type:Silhouette image of generic A109 model; specific model in this crash may look slightly different
Agusta A109E Power
Owner/operator:New Mexico State Police
Registration: N606SP
C/n / msn: 11209
Fatalities:Fatalities: 2 / Occupants: 3
Other fatalities:0
Aircraft damage: Substantial
Category:Accident
Location:near Santa Fe, NM -   United States of America
Phase: Take off
Nature:Survey
Departure airport:
Destination airport:Santa Fe, NM (KSAF)
Investigating agency: NTSB
Narrative:
On June 9, 2009, about 2135 mountain daylight time, an Agusta A109E helicopter, N606SP, impacted terrain following visual flight rules flight into instrument meteorological conditions near Santa Fe, New Mexico. The commercial pilot and one passenger were fatally injured; a highway patrol officer who was acting as a spotter during the accident flight was seriously injured. The entire aircraft was substantially damaged. The helicopter was registered to the New Mexico Department of Public Safety and operated by the New Mexico State Police (NMSP) on a public search and rescue mission to find a hiker who had become lost in the Pecos Wilderness Area about 20 miles northeast of Santa Fe and was feeling very cold.
The helicopter departed its home base at Santa Fe Municipal Airport, Santa Fe, New Mexico, about 18:50 in visual meteorological conditions; instrument meteorological conditions prevailed when the helicopter departed the remote landing site about 21:32.

The National Transportation Safety Board determines that the probable cause of this accident was the pilotís decision to take off from a remote, mountainous landing site in dark (moonless) night, windy, instrument meteorological conditions.
Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilotís fatigue, self-induced pressure to conduct the flight, and situational stress. Also contributing to the accident were deficiencies in the NMSP aviation sectionís safety-related policies, including lack of a requirement for a risk assessment at any point during the mission; inadequate pilot staffing; lack of an effective fatigue management program for pilots; and inadequate procedures and equipment to ensure effect

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20090610X23159&key=1

Safety recommendations:

Safety recommendation A-11-53 issued 10 June 2011 by NTSB to State of New Mexico
Safety recommendation A-11-54 issued 10 June 2011 by NTSB to State of New Mexico
Safety recommendation A-11-55 issued 10 June 2011 by NTSB to State of New Mexico
Safety recommendation A-11-56 issued 10 June 2011 by NTSB to AIRBORNE LAW ENFORCEMENT ASSOCIATION
Safety recommendation A-11-57 issued 10 June 2011 by NTSB to AIRBORNE LAW ENFORCEMENT ASSOCIATION
Safety recommendation A-11-58 issued 10 June 2011 by NTSB to AIRBORNE LAW ENFORCEMENT ASSOCIATION
Safety recommendation A-11-59 issued 10 June 2011 by NTSB to AIRBORNE LAW ENFORCEMENT ASSOCIATION
Safety recommendation A-11-60 issued 10 June 2011 by NTSB to National Association of State Aviation Officials
Safety recommendation A-11-61 issued 10 June 2011 by NTSB to National Association of State Aviation Officials
Safety recommendation A-11-62 issued 10 June 2011 by NTSB to National Association of State Aviation Officials
Safety recommendation A-11-63 issued 10 June 2011 by NTSB to National Association of State Aviation Officials
Safety recommendation A-11-64 issued 10 June 2011 by NTSB to International Association of Chiefs of Police
Safety recommendation A-11-65 issued 10 June 2011 by NTSB to International Association of Chiefs of Police
Safety recommendation A-11-66 issued 10 June 2011 by NTSB to International Association of Chiefs of Police
Safety recommendation A-11-67 issued 10 June 2011 by NTSB to International Association of Chiefs of Police

Accident investigation:
cover
  
Investigating agency: NTSB
Status: Investigation completed
Duration:
Download report: Final report


Images:


Revision history:

Date/timeContributorUpdates
11-Jun-2009 06:35 slowkid Added
11-Jun-2009 06:37 slowkid Updated
11-Jun-2009 06:51 slowkid Updated
11-Jun-2009 23:20 slowkid Updated
27-Jan-2010 09:53 FLYINGBROTHER1 Updated [Date, Aircraft type, Nature, Departure airport, Destination airport, Source]
23-Dec-2011 12:43 Anon. Updated [Source, Damage]
26-Mar-2013 09:52 TB Updated [Operator, Location, Source]
26-Mar-2013 10:29 TB Updated [Time, Operator, Source]
06-Sep-2014 14:29 Aerossurance Updated [Time, Phase, Nature, Departure airport, Destination airport, Source, Narrative]
21-Dec-2016 19:25 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
02-Dec-2017 15:38 ASN Update Bot Updated [Operator, Other fatalities, Nature, Departure airport, Destination airport, Source, Narrative]
20-Dec-2018 17:09 liamdaniel98 Updated [Nature, Embed code]
20-Dec-2018 17:17 harro Updated [Other fatalities, Nature, Departure airport, Destination airport, Embed code, Damage, Narrative, Photo, Accident report, ]

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